=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487972287
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PENNY MEDICINEBEAR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/04/2010
-----------------------------------------------------
Last Update Date | 05/04/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 324 SUNSET AVE
-----------------------------------------------------
City | SMITHS GROVE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42171-8164
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-784-7079
-----------------------------------------------------
Fax | 270-451-1200
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 433 324 SUNSET AVE
-----------------------------------------------------
City | SMITHS GROVE
-----------------------------------------------------
State | KY
-----------------------------------------------------
Zip | 42171-0433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 270-784-7079
-----------------------------------------------------
Fax | 270-451-1200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MR. MICHAEL FUQUA MEDICINEBEAR
-----------------------------------------------------
Credential | N/A
-----------------------------------------------------
Telephone | 270-784-7079
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number | 3586
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 344600000X
-----------------------------------------------------
Taxonomy Name | Taxi
-----------------------------------------------------
License Number | 3585
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------